Dementia now linked to cigarette smoking

Several years back on this blog a study was discussed that proved a relationship with COPD and dementia.  I haven't seen much else on this subject until a March 3, 2014, post "COPD and Cognitive Loss," by Valerie Neff Newitt, at Advance: Respiratory Care and Sleep Medicine.

The article suggests that, if telling a patient that COPD is now the #3 cause of death isn't enough to convince them to quit smoking and make the necessary lifestyle changes necessary to improve lung function.

The article is based on a recent study by the Mayo Clinic that confirmed the earlier findings, adding that, acccording to  Newitt, people with COPD are twice as likely to develop mild cognitive impairment (MCI), which is a fancy way of saying early dementia.

So now we can pretty much add dementia to the long list of co-morbidities associated with COPD, diseases which are linked to smoking cigarettes, which include the top four causes of death in America: heart disease, cancer, lung disease, and stroke.  It also includes diabetes, allergies, infertility, gum disease, and ulcers.

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Two types of COPD patients

Graph from the British Medical Journal

Smoking has, for a long time now, been associated with chronic obstructive pulmonary disease (COPD).  The interesting thing, however, is that the truth is only a small percentage, about fifteen percent, of those who smoke are diagnosed with the disease.  

Why is this?  No one knows.  However, a logical theory is that people with a certain genetic makeup may be more susceptible to the effects of smoking. Another theory is that this poor genetic makeup may include, among others, the asthma gene.  

However, if we refer to the Fletcher and Petco Curve

That said, Scott Cerreta, in his May, 2013, column in AARC Times, "It's Never Too Late To Stop Smoking," defined the two types of COPD:Average smokers:

1.  Average smokers: Heavy daily smokers not susceptible to the effects of smoking, and do not seem to have a significant enough decline in lung function as determined by FEV1 (pulmonary function testing) to result in COPD flare ups. 

2.   Susceptible smokers:  Heavy daily smokers who are susceptible to the effects of smoking, and do have a significant loss of lung function to cause COPD flare ups, and this generally begins to occur at the age of 35-45.  Generally, the first symptoms are overlooked, and loss of lung function so gradual, that the person may not even notice it until struck with a severe flare up that requires a trip to the emergency room. 

Quitting smoking sustains lung function

Figure 1

A little over four years ago I wrote about the Petco Curve, which is shown here.  It essentially shows that the fewer cigarettes you smoke, the longer you live.
Yet the greatest part of this graph is that it offers proof that quitting smoking, at any time in your life, can slow down the breakdown of lung function, and prolong your life.

Despite the significance of this graph, I have not seen much written about it over the years, until Scott Cerreta wrote his column, "It's never too late to stop smoking," in the May, 2013, issue of AARC Times.

Of this graph, he said:

"Sustained smoking abstinence is one of just a few interventions that has been proven to prolong life for those living with COPD.  Tobaco cessation is the only intervention that actually slows disease progression by reducing the rate of lost lung function for the susceptible tobacco smoker.  Unfortunately, individuals with COPD cannot normalize their lung function after qu;itting, but most patients will improve their FEV1 (lung function) within the first year of tobacco abstinence.  The most important point is that for 'susceptible smokers' with COPD, sustained smoking abstinence significantly slows the rapid loss  of lung function as seen in figure 1."

The interesting thing about this graph, Cerreta explained, is that it shows that the lung function of people who smoke gradually declines even in those with average COPD, or those who do not observe symptoms of lung declines and who do not have COPD flare ups.

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Grandpa's quote about smoking

She smokes.  She said, "You know, I know they want me to quit smoking, but I'm just not going to do it.  I have no interest in quiting.  I really enjoy it."

I said, "I understand what you're saying.  I tried to get my grandpa to quit smoking when I was a kid and he said, "I would rather do the things I enjoy and live a short and happy, as opposed to giving up what I enjoy and living an unhappy long life."

She said, "Can you please write that down for me, I want to script it and hang it on my wall for my kids to see."

I did. 

WHO spins facts about 2nd hand smoke

My uncle, who so happened to be a chain smoker, educated me one day about the fallacy that 2nd hand smoke caused cancer. He was a chain smoker, and he already had a lung removed, yet he still felt the facts were so that it was worthy to note the "bullshit that THEY teach kids these days."

At the time I just blew my uncle off as a smoker who didn't want to admit the truth. Yet being the person I am (and perhaps partly through his example), I decided a better response to his little speech was to do my own research.

In doing so I came upon this study that was independently funded by the World Health Organization (WHO). The study was a review of many other studies on the subject, and the goal was to prove that 2nd hand smoking causes cancer.

Ironically, the study proved the opposite: that 2nd hand smoke does not cause cancer. Yet since the study didn't show what they wanted, they didn't release it. They didn't do this because one of the goals of the progressive WHO is to create an ideal world. And in an ideal world people don't smoke because smoking kills.

Now it is still true that 2nd hand smoke is unhealthy, and most studies about it show this. Yet it is just about a proven fact now that 2nd hand smoke does not cause lung cancer. The WHO was hoping this study would help justify their attempts to get rid of smoking worldwide through higher taxes and laws banning it in public places.

The ultimate goal of the WHO is to ban smoking altogether, yet because of the U.S. Constitution, this is nearly impossible to do because people have a Constitutional right to be stupid so long as they don't infringe on the rights of others. Ideally, the Constitution protects us from each other, and not necessarily from ourselves. So if we want to smoke, so be it.

Of course another reason progressives want to get rid of smoking altogether is because another goal is universal healthcare. They don't want to pay for the health consequences of personal choices that are bad, like smoking.

This is yet another reason I'm opposed to universal healthcare, and even Obama care, because if someone is paying your bills, they have a right to tell you what to do. In other words, you are a slave to the person you are in debt to.

Thus, every time a new law is made, you lose another freedom. Every time we receive another government entitlement, we lose another freedom. So if we continue to allow our government to create more government programs, we will eventually be slaves to the state. The same thing happened in ancient Rome, and destroyed that republic.

The WHO once again has ignored the above mentioned study as it released a new study that shows that 2nd hand smoke kills up to 600,000 people each year, and this accounts for 1% of all deaths each year. You can read the report here.

The report notes that, "Researchers estimated that annually second-hand smoke causes about 379,000 deaths from heart disease, 165,000 deaths from lower respiratory disease, 36,900 deaths from asthma and 21,400 deaths from lung cancer."

In lei of the previous study by the NWO that showed 2nd hand smoke does not cause lung cancer, can we now assume the NWO is conveniently ignoring this study. Their ultimate goal is to get rid of smoking, regardless of facts.

This almost makes one wonder about the true intentions of progressives. Are they after what's best for the people, or the government? I almost think they want to get rid of smoking so the government doesn't have to pay for diseases caused by smoking.

So they raise taxes. They also create more rules or laws that ban smoking in public places. All of this with the intent of forcing people to quit, as opposed to people quitting by individual choice. Progressives don't believe in individual choice, the believe in the state making choices for the people.

Of course, as I've written before, too many rules (laws) and too high of taxes result only in people finding ways to get around the taxes or rules. It creates a world of cheaters and liars, because the natural tendency of human beings is to make their own decisions. People don't like people telling them what to do.

A great example of this is in New York where taxes are high on cigarettes and public smoking is not legal, a black market for cigarettes has been created, as you can read here.

I have no vested interest in people smoking. Well, I say that knowing that my career as an RT is mainly funded by patients who smoke. Yet I don't want people to smoke. It bothers my asthma when people smoke around me. It threatens the health of my kids.

So I don't want people to smoke. I want people to quit. I want my dad to quit, yet he has made the personal choice to smoke. And, yes, he does get cigarettes illegally over the Internet because he can get the cheaper that way.

Second hand smoke is bad as you can see by any link that lists the hazards of second hand smoke, such as this and even the WHO itself as you can see here.

You should educate your patients about the dangers of 2nd hand smoke. If someone says they quit smoking, make sure they know to not let others smoke around them. Yet also don't get all your wisdom from one place, and decide for yourself what is fact and what is not a fact.

Because Lord knows it's hard to get all the facts even from sources we otherwise think are trustworthy. Now I'm certain the American Cancer Society and other such resources are trying to provide honest facts. Yet they, like you and me, get their wisdom from sources they hope are being honest with us.

This is a perfect example of why I created this blog. You and I are interested in facts and then we make an educated decision, rather than just believing everything we read. While we might not have much of a choice what we do as RTs, we can be smart.

Facts about 2nd hand smoke

Here are some facts about 2nd hand smoke. This list may be different from other lists because I'm basing my list on facts obtained from studies and not my own personal opinion and vested interest.

Note, however, that I want people to quit smoking, and I want people who do not smoke to be protected from 2nd hand smoke. However I do not believe there should be any attempt by any government to force people to quit smoking other than through education.

It is my belief that most people are smart, and provided with facts they will make the best decision for themselves. I do not believe facts come from organizations and companies that in some way profit from smoking. I also do not believe the facts come from organizations like the World Health Organization (WHO) either.

In a way this is frustrating, because ideally we should be able to get all our facts from such organizations as the WHO, our government, or at least from the Media. Yes it's true, even the media can't fully be trusted.

So this is why we must keep our minds and ears open and get our news from a variety of sources. While I do not pretend to know all the truths, I do like to lay out all the facts so we can all make an educated decision. This, after all, is the goal of the RT Cave.

We do, however, agree that 2nd hand smoke is bad, even though all the information we receive might be twisted in one way or another. That in mind, here are some facts about 2nd hand smoke.

1. 2nd hand smoke may not cause lung cancer, as you can see by this WHO study. Despite this, the WHO notes that 2nd hand smoke kills as many as 600,000 people each year, as you can read here. We're neutral here, so you decide.
2. There are over 4,000 chemicals in cigarette smoke, and over 250 of them are known to cause damage to the human body such as aging the body, thinning the skin and arteries, destroying cilia in the lungs, etc. This effect is just as damaging to those who breath second hand smoke as those who inhale the smoke directly.
3. It causes 600,000 premature deaths each year
4. It causes hardening of arteries and heart disease (about 46,000 deaths annually)
5. It increases your risk for stroke and brain aneurysms (thinning arteries)
6. It increases your risk for getting chronic obstructive lung disease, especially if you have asthma
7. It increases your risk for getting pneumonia
8. It shortens your lifespan (yes, even if you inhale someone else's smoke)
9. Separate areas in a building to not decrease your risk for second hand smoke related exposure. This is why smoking sections have no effect.
10. Ventilation systems do not decrease your risk of inhaling 2nd hand smoke. Smoke can get from a smoking area to a non smoking area even if there's a door between rooms.
11. 40% of children are exposed to smoke at home.
12. 31% of smoking related deaths occur in children
13. 2nd hand smoke greatly increases the risk of sudden infant death syndrome
14. 2nd hand smoke increases risk your child will develop asthma
15. Kids exposed to 2nd hand smoke are 1.5 to 2 times more likely to smoke themselves
16. Results in increased sick days and lost wages
17. Increases economic costs to society by forcing all of us to pay for the care of smoking related diseases and smoking cessation programs
18. Decreases lifespans (each cigarette takes 7 minutes off your life)
19. The World Health Organization notes that, "More than 94% of people are unprotected by smoke-free laws. However, in 2008 the number of people protected from second-hand smoke by such laws increased by 74% to 362 million from 208 million in 2007. Of the 100 most populous cities, 22 are smoke-free. (Note here, however, that a government has the job of protecting us from each other, but not from ourselves)
20. Other breathing problems in non-smokers, including coughing, mucus, chest discomfort, and reduced lung function
21. 50,000 to 300,000 lung infections (such as pneumonia and bronchitis) in children younger than 18 months of age, which result in 7,500 to 15,000 hospitalizations annually
22. Increases in the number and severity of asthma attacks in about 200,000 to 1 million children who have asthma
23. More than 750,000 middle ear infections in children
24. Pregnant women exposed to secondhand smoke are also at increased risk of having low birth- weight babies.
25. It may be linked to breast cancer
26. Causes premature death and disease in children and in adults who do not smoke.
27. Smoking by parents causes breathing (respiratory) symptoms and slows lung growth in their children.
28. Secondhand smoke immediately affects the heart and blood circulation in a harmful way. Over a longer time it also causes heart disease and lung cancer.
29. The scientific evidence shows that there is no safe level of exposure to secondhand smoke.
30. Many millions of Americans, both children and adults, are still exposed to secondhand smoke in their homes and workplaces (a cause of occupational asthma) despite a great deal of progress in tobacco control.
31. The only way to fully protect non-smokers from exposure to secondhand smoke indoors is to prevent all smoking in that indoor space or building. Separating smokers from non-smokers, cleaning the air, and ventilating buildings cannot keep non-smokers from being exposed to secondhand smoke.
32. Driving in a car with the cigarette dangling out the window does not mean other people in the car will not be exposed to 2nd hand smoke

The following are facts about 2nd hand smoke some may not want you to know:

1. 2nd hand smoke may not cause lung cancer, as you can see by this WHO study. Despite this, the WHO notes that 2nd hand smoke kills as many as 600,000 people each year, as you can read here. We're neutral here, so you decide
2. The WHO also learned that parents smoked had had a 22% better chance of NOT contracting lung cancer than did adult children who came from homes where both parents did not smoke. WHO tried to hide this fact
3. The WHO has a vested interest in getting people to quit smoking because they believe governments should have universal health care, and smoking would therefore increase economic costs to various governments.
4. Despite what the WHO mentioned above, some studies show that technology such as air filtration systems in bars to filter as much as 100% of 2nd hand smoke from the atmosphere of the building. So ventilation systems can be effective.
5. The number of deaths caused by 2nd hand smoke is often exaggerated. The study showing 2nd hand smoke does not cause lung cancer, and the fact 2nd hand smoke is still attributed to 2nd hand smoke, is a perfect example. The WHO and the Environmental Protection Agency have invested interests in exaggerating these numbers.
6. Most people do not approve of smoking bans in public places. For example, in New York 85% said such laws went too far (however, personally, I believe such laws are necessary and Constitutional. The Constitution gives lawmakers the right to protect us from each other. However, I think such laws should give businesses the right to be smoke free or not smoke free and the people can choose whether or not to go to the businesses that allow smokers inside. Let the market decide and not some lawmaker in Washington).
7. There are no studies that show people miss more work due to 2nd hand smoke. There are many reasons people miss work, and none could be ruled out. It could be second hand smoke, but there's no real evidence to show this.
8. There is no real proof smoking increases medical costs. There is no proof these people would have had medical problems regardless whether they smoked or not. There is proof that people who smoke and have increased health problems have bad genes, so perhaps these people would have had bad health regardless that they smoked (or inhaled 2nd hand smoke).
9. Even scientific studies are interpreted by people who have biases. Questions can be asked to generate a certain response. Studies can be interpreted with bias. In this way, sometimes statistics can be skewered.
10. It is a fact that some studies show 2nd hand smoke causes certain diseases, and similar studies that show the opposite. As we can see by the WHO, the ones that are inconvenient to the biases of the organization are ignored and those that prove the bias are reported.
11. The smoking industry lied about the dangers of 2nd hand smoke until recent years. This is why some smokers have succeeded in suing these companies.
12. The U.S. government knew prior to WWI that smoking was dangerous to people's health, yet still gave out free cigarettes to soldiers in WWI and WWII. The U.S. government succeeded in getting America addicted to cigarettes knowing it was bad in order to help the smoking industry in order to boost the economy. This is a fact. Look it up for yourself.
13. In 1929 a study was published in Germany linking cigarette smoke with lung cancer (see here).
14. Automated cigarette machines were invented in the late 19th century which made it easy to make cigarettes. The industry soon took off, and it boomed with the help of the U.S. government

The above facts were obtained from common wisdom, the World Health Organization, the American Cancer Society, Citizens Freedom Alliance, Inc,

Stop Smoking Aids

This is part 2 of a series by Tim Frymyer from over at Stopsmokinghelper.org. To view part 1 in this series, click here. To view part 2 in the series click here.

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Today I thought I would talk about the world of stop smoking aids. You know, it still amazes me that smoking retains such widespread popularity in the United States despite all the Surgeon Generals warnings and tobacco company lawsuits. Roughly a quarter of all Americans are still smoking. As we all know, in many parts of the United States, smoking is as part of the mainstream culture as baseball and apple pie.

Currently, there are many stop smoking aids, methods or products on the market. Everything from electric cigarettes to lasers. But when you get past the hype and look at the science of smoking cessation, you are left with a very stark reality, low success rates. Let's look at the most popular methods for smoking cessation.

The first category can be called non-pharmacologic means. This includes quitting cold turkey, behavior modification, and support groups/counseling. Quitting cold turkey, although the preferred method of quitting by most smokers, offers the lowest success rate at around 3-5%. People seem to quit smoking cold turkey everyday. There is something in our DNA that takes pride in the idea of quitting without any help. Quitting cold turkey also gives the person a chance to "test the waters" of cessation without anyone else knowing about it. So if they fail or relapse, then their ego doesn't have to take a hit.

In contrast though, group counseling and behavior modification has the highest success rate, right around 20%. However, there is often a stigma associated with counseling in our society and so very few smokers will choose this option, despite the relatively high quit rates. This route to becoming smoke-free is wrought with lots of exposure and many don't want to admit they need help or are simply not that serious about quitting yet. So as a result, if I may borrow a poker term, they don't go "all-in".

The second category would then be pharmacological interventions. Here is where you see nicotine replacement therapy (NRT), like nicotine gum, the patch, the nasal spray, etc. You'll also find Zyban and Chantix in this category.

The success rate found with nicotine replacement is about equal to what is found with Zyban, which is basically double that of quitting cold turkey, right around 7-10%. NRT comes in a variety of forms, some expensive and some cheap. Some require a physician script, while others are OTC. I had one smoker tell me that he thought NRT was horrible because it didn't cure him of his smoking habit. After further questioning, he explained that he just wanted to "try" something different from cold turkey which had also failed him. So I believe smokers have this perception that you first try cold turkey, then NRT, then the next method and so on and so forth until you eventually quit.

Zyban is an anti-depressant which not only shows some smoking cessation properties, but also can help to treat some of the underlying depression associated with smoking. If smoking were a disease, which many feel it is, depression would be a primary co-morbidity. For many, Zyban is a good option because of the psych treatment component.

Chantix is a pill which boasts a success rate above 20%. However, Chantix has been required by the FDA to place a warning label on each box dispensed. The label warns the consumer that some who take Chantix, have experienced erratic and bazaar behavior. Many who want to quit smoking may not be willing to take that chance, in spite of the potential upside in success. But Chantix also utilizes a "program" for smoking cessation. They don't look at it as simple a “magic bullet“, but rather a piece in a complex support system to help smokers quit. There are some who believe that it is the support and not the pill that provides the high success rate seen with Chantix. Remember, counseling has a very high success rate by itself. So regardless of the method used, the addition of a counselor or behavior program will greatly increase the likelihood of cessation.

There is one more pharma category that many people like to use and that is what I call the placebo method - this group wouldn't be classified as front line though. This is where someone takes a legitimate medication with a very real medical use but offers it up as a stop smoking aid in an "off-label" manner. In other words, they may take some benign medication used to dry up secretions, and market it as a stop smoking shot. The consumer then receives this medication thinking they are getting some new smoking cure. This idea is so powerful, it creates a very real placebo effect in their mind. You’ll also find the “natural smoking remedies” in this category too. Various herbs mixed together to form a cessation cocktail of sorts. Again, it’s not so much the product that counts, but the advertising. The buyer needs to really believe the product will work. The success rates for placebo is thought to be about equal to that of quitting cold turkey, as you would expect.

The final category is what I label as alternative methods. This sort of catch-all group is where you find hypnosis and acupuncture (both traditional and laser). These methods might have a basis in non-traditional science and certainly have helped people to stop smoking. But there is sometimes no rhyme or reason as to whether it will or will not work; which, I suppose, doesn't make them much different than any other method. Like placebo meds, there are no studied success rates with these methods and there are no clinical studies to quote statistics from. But most agree, the success is equal to that of quitting cold turkey.

After looking at these success rates, it becomes easy to see why smoking is still so prevalent. Too often people buy into a product or method because it offers them the magic bullet. But in the end, they're just not mentally prepared for the grind. So how do we improve our results then? Many researchers and experts agree that education and information is what smokers need. Only then can they connect the dots between behavior, treatment and commitment.

As therapists, we need to help our patients set realistic expectation and help them select the best stop smoking aid that suits their personality and addiction. Simply put, knowledge has to be the driving force. The better informed someone becomes, the more sound their expectations will be and the more success they'll have.

This is one reason why I created a literature-based stop smoking website. I wanted it to be a resource for RTs and other healthcare professionals so they could talk intelligently about smoking cessation with their patients. I have a stop smoking aids page on my site that is a great resource for anyone who wants more information on the subject.

Thanks again to Rick for allowing me to share this information.

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Related links:

• Stop Smoking Help
  
• Smoking cessation program
• Smoke and have asthma: here's 20 incentives to quit
• More good reasons to quit smoking
• Stop smoking in front of your kids. Period!
  

Is nicotine addictive?

This is part 2 of a series by Tim Frymyer from over at Stopsmokinghelper.org. To view part 1 in this series, click here. To view part 3, "Stop smoking Aids" click here.

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Thanks again to Rick for letting me occupy the Respiratory Therapy Cave for another day to discuss the topic of smoking cessation. Today we’ll look at addiction. For over fifty years now, people have been telling us that smoking is addictive. The nicotine is said to increase the levels of dopamine in your brain which then gives the smoker that pleasure sensation or that feeling of satisfaction, every time they inhale. In fact, the brain produces more receptors to accommodate more and more nicotine, in an effort to get more of that feeling. Researchers state that over 85% of all smokers are addicted to nicotine. Given the low success associated with smoking cessation aids and the relatively high rate of recidivism or relapse, it is easy to see how one could come to the conclusion that nicotine is addictive. In fact, nicotine is said to be as or even more addictive than opium or cocaine.

The second part of habitual smoking is the behavioral side. We humans are creatures of habit and tend to associate certain activities together. For example, we all know people who smoke only when they drink. Those two behaviors are said to be associated or linked. Many smokers take cues from their environment which then trigger that smoking response. Often times these are simple cues like finishing a meal, driving to work, or some other basic, repeated cue that occurs throughout the day. Behaviorists say that the act of smoking takes on a Pavlovian response to environmental triggers. Adding this classic conditioning makes smoking a difficult one-two punch to beat.

However, new research from Tel Aviv is challenging the assumption that smoking causes a physiological addiction, like heroin. In the Journal of Abnormal Psychology, Dr. Reuven Dar examines the idea that smoking may be a simple case of mind over matter. His premise states that smoking's primary driver is behavioral. He feels these triggers are so strong, they cause the appearance of physiological addiction. His study looked at a simple measurement tool, craving intensity on regular smoking days, a voluntary day of abstinence and the required smoking cessation on the Sabbath.

His findings show that cravings on the Sabbath were less intense when the smoker knew they couldn't smoke. However, the cravings on the day of abstinence were just as strong as the regular smoking days. This lead Dr. Dar to conclude that when the individual knew they couldn't smoke, they were not showing the addictive calling card, intense cravings, that were present on every other day; in essence, mind over matter.

I think we all would agree that smoking addiction is a very complex physiological theme to dissect, though there just may be something to Dr. Dar's research. After treating thousands of patients in the hospital, it has been my experience that once the patient had made up their mind to stop smoking, it didn't really matter what method they used, they simply stopped. And they seemed to stop without any trouble. I’m sure you all have had similar experiences with your patients as well.

Skeptics, however, will argue this “mind over matter” concept. Research is still warranted to determine just which side of the addiction represents the most influencing motivation to smoke. In fact, there is also new research out of Duke University pointing to a smoking gene which, when present, can predict how successful a person will be when trying to quit. However, this genome testing is very expensive and still in it's infancy.

But I believe the idea founded in Dr. Dar’s research can give us a unique opportunity for education when we talk with our patients. Many patients feel quitting is just too difficult, especially in light of the very real stress they may be feeling about their current physical condition. However, we can give them hope and perhaps convince them that quitting may just be as simple as making a decision, followed by another decision and another. Simply resolving each day to quit, might be the “trick” our patients have been looking for

While you're at it, add this to Our Job Title

Regular readers of my blog know that I'm an ardent believer that the best way to get people to quit smoking is through education.

So when Tim Frymyer, RRT, and creator of StopSmokingHelper.org informed me about his new website, and his desire to write a guest post for the RT Cave, I eagerly accepted his proposal.

Check out his post published below, and then be sure to check out the new website he created with the intent of helping smokers quit. Enjoy.

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I'd like to first thank Rick for letting me post something in The Cave. I believe it is an honor and I hope the information lives up to his standards. Let me start off by telling you all a little about my experience as a therapist. I started 20 years ago in Dallas at the county hospital and then moved on to a private non-profit. All the time, I’ve worked exclusively with adult and geriatric patients. I have all the respect in the world for RTs who work with neonates and peds, because to this day, they still scare me. I'm not sure why exactly, I'm just more comfortable with adult patients. My co-workers would tell you it’s because I like to talk. They might be right.

Anyway, I've been a bedside therapist, run a pulmonary lab, presented numerous educational seminars and finally, managed my department for about 5 years. So given all that experience, I've come to realize that RTs who work in the adult-side of patient care have 1 industry to thank for our job security, our bread and butter as it were. Yes, that would be the tobacco industry. No real surprise here.

Sure, we treat asthmatics, post-op patients, and we can't wait for that next difficult ARDS case, but our primary energies are spent taking care of people who have bad lungs, a bad heart or some other disease related to their smoking. This is what compelled me from the bedside world to the virtual world and hence, the creation of "http://www.stopsmokinghelper.org/". I figured it was time to be a little more proactive instead of reactive. If I could help just one person stop smoking, then that would be one less patient some therapist may have to treat.

Currently, smoking in this country costs us, the taxpayers, over $193 Billion. That total is based on lost productivity and both direct and indirect healthcare costs. Back in 2004, COPD by itself costs Americans $37 Billion. So while everyone is talking about healthcare reform and Obamacare, think what would happen if everyone just stopped smoking?

Let that sink in for a while. We'd be talking about the roughly 20% of our population that smokes, laying down their packs and lighters. That sounds like some kind of Twilight Zone episode doesn't it?But right off the top, you're talking about eliminating the 90% of all lung cancer cases related to smoking. What would happen to the lesser known diseases that smoking is a risk factor for like: osteoporosis, oral cancer, stroke, prematurity of infants, SIDS, bladder cancer, your kid's childhood ear infections, etc.? All these are risk factors of smoking. Now we're talking about making a real impact on universal healthcare reform.

What about the human element though? How many people would you say die in the U.S. because of smoking; 10,000, 50,000, 100,000 people? Well, you're getting warmer, roughly 400,000 deaths every year are attributable to smoking. That's 1 in 5 deaths in the United States (according to the CDC). It's kind of funny, because I will occasionally still read pro-smoking blogs that deny the overwhelming statistics associated with smoking and smoking related disease. To them, it's all one big conspiracy created by the government and big pharma. They believe that people who suffer from COPD, lung cancer or other smoking related illnesses, are just the exception to the rule, rather than the rule itself. Oh, if they could only round with us for one week in the hospital, then they’d see the truth.

Well, I hope I have convinced you that part of our job as respiratory therapists is to educate our patients and their families to the very real dangers of smoking. Most of my patients are very glad to discuss the topic in the hospital setting, but will typically dismiss the idea once they're discharged and feeling better. However, if we had a way of giving them something or following up with them on discharge, they might have a greater motivation and/or desire to quit smoking. We have to strike while the proverbial iron’s hot. Getting them in contact with a program or service while still in the hospital is a great way of helping the patient become smoke-free. Simply getting the patient to talk with his or her physician can greatly improve their chances of success, so feel free to employ their GP in your education efforts.

Here is one example of what this might look like. When I left the acute care world, we had just implemented a therapist-based smoking cessation program that did involve a 1-week post-discharge phone call by one of our therapists. We were fortunate in that these therapists were also in our asthma clinic, so it wasn't a stretch on our staff's resources to have them perform this task. I know not every facility has this luxury. But at the very least, you can leave them with some kind of a resource in their hands like a phone number to a quit center. Then you’ve at least done your part.

Ultimately though, it's up to the patient, isn't it? I never met a patient who quit because I asked them to. They have to be convinced and committed to the idea that smoking cessation is in their best interest. It's simply up to us, to help paint that picture while we're waiting for the albuterol to nebulize. So make use of your time wisely and help get the message out. Oh, and one of the best times to bring it up is when the family is in the room. Grandkids and little children can be the best motivation to help someone quit.

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Stay tuned. This post is part 1 of a series. To view part 2 click here.

Related links:

• Smoking cessation program
• Smoke and have asthma: here's 20 incentives to quit
• More good reasons to quit smoking
• Stop smoking in front of your kids. Period!
  

Never quit quitting

So I had an early stage COPD patient today, and as is my job, I encouraged her to quit smoking. I didn't go as far to say she HAD to quit, but more so provided her with the ammo, and the incentive to do so, and pointed her in the right direction. That's, basically, how it goes. We RTs (as do RNs) plant seeds, and hopefully these seeds eventually blossom.

Yet this patient was adamant she wasn't going to quit smoking, "I love smoking. I have no interest in quitting. I love smoking when I have coffee in the morning, lunch, dinner, break at work. I just love it. Of course I know smoking is bad, but I don't want to quit. I know I should, but... you know."

"However, "I said, "Here is the information you need to quit. When you're ready to use it, you have it at your fingertips. Read up. Know what works best. Know the facts."

"Um, my doctor provided me with a pamphlet, and it said within 10 years your risk of other diseases goes down, but he said your COPD will keep progressing anyway. So I think: what's the point."

"I think you misunderstood your doctor. Either that or he's dead wrong. Because by all the facts I've read, your COPD will never go away if you quit, but it will be a lot easier to manage, progression will be slowed way down, and you will be able to live as you are now for a lot longer."

"Still," she said, "It's something I love to do. My daughter smokes too, and my husband. We just love doing it together."

Denial. The first step is admitting you have a problem. And that's the great thing about this country is you have a right to be stupid. However, I think this lady wants to quit, yet it's easier not to. It's easier to make excuses.

She said her grand daughter keeps trying to get her to quit. I said, "You should quit for her, so you can be around as she grows up."

"Yeah," she said, "But if it's gonna be, it's gonna be."

I told her I understand her completely. I remember teasing my grandpa when I was a kid, that he should quit. He said, "I'd rather smoke, enjoy life, and be happy, and die young than live to be 100 and not have enjoyed life as I do now."

I understand grandpa completely. However, when he started smoking, the facts about the dangers weren't plastered everywhere as they are today. There are way too many facts, too many studies, that show smoking, and second and third hand smoke, is dangerous. Too many studies that show quitting is beneficial in every single way you can think.

"I know I'm going to sound like a parent when I say this," I said, "But you're responsible for your decisions. I understand your quest to be happy, but there are other things you can do to find happiness than smoking."

"You're completely right," she said, "I'm glad I had this talk with you."

While I think she means well, I have seen too many ladies (and gentlemen) in her situation, and way too many decide that quitting simply isn't worth it. And I have to watch them die over the next few years. It's the sad truth of this job.

Yet it's our jobs to never quit urging them on.

The ideal Smoking Cessation Program

Another responsibility laid upon us respiratory therapists is educating our patients who smoke on the importance of quitting. Most smoking cessation programs are fully reimbursed by most insurance companies, Medicaid and Medicare.

I always felt I was overstepping my bounds telling my patients they ought to quit. That was until I saw the latest statistics. The fact is, 70% of smokers say a health care professional has never told them to quit, and yet 70% of smokers say they want to quit.

Likewise, with the help of a clinical professional, the odds of a person quitting doubles. On top of that, the chances are that smoking is probably what caused and exacerbated the illness that caused the patient to be in the hospital in the first place. Smoking is also known to slow the immune process which delays healing. Quitting smoking, therefore, can prevent such an occurrence from re-occurring in the future.

Also, According to the CDC, " Constituents in tobacco smoke (e.g., polycyclic aromatic hydrocarbons) may enhance the metabolism of drugs, resulting in a reduced pharmacologic response. Smoking might adversely affect the clinical response to the treatment of a wide variety of conditions."

The job of the RT is not to finish the program, just start it. All we have to do is remind the patient of the importance of quitting, and what are the latest recommendations or products to help them quit, and then show them what steps they need to get started. Ultimately, our job is to nudge the patient.

The following is what the Michigan Department of Community Health recommends we do:

1. Ask about tobacco use at every visit:

• Advise patients to quit: "I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future."
• Link current illness and tobacco use (Condition x is caused or worsened by smoking)
• Counsel on proper use of cessation medications
• Review the benefits of behavioral counseling

2. Assess readiness to quit: The Average person takes 9-11 attempts

3. Refer patient to tobacco quit line, or provide patient with tobacco quit kit

• refer to the Michigan Tobacco Quitline (1-800-480-QUIT)
• Refer patient to a self help quit book like this one.

4. Encourage the patient by emphasizing that quitting is possible.

5. Address ambivalence by reminding patient that it is normal to be scared about quitting smoking, and "getting stuck there is not!" Try to get them to look at the advantages of quitting smoking; of how they will be healthier; "Is there any way at all in which you’d be better off if you quit? That might be something to think about."

Types of ambivalence include:

• The products don’t work: The truth is, medications significantly improve quit rates, and all smokers should be encouraged to use them. If they didn't work in the past, it's because they weren't used properly, or the wrong dose was prescribed. Make sure the patient understand how to take medicine properly, and that they never quit. Encourage patient to use on a steady basis, and not as needed.
• I’m trading one addiction for another: Nicotine is absorbed from the lungs and reaches the brain in 11 seconds. That's what makes smoking so addictive. Cessation meds provide nicotine very slow, and therefore it's harder to get addicted. Also, it's easier to wean off the meds than cigarettes.
• I can quit on my own:
  Fewer than 5% of people who quit without assistance are successful in quitting for more than a year. Most people do not succeed on their own, and medications double your chances of quitting.
• NRT is harmful: NRT is the nicotine used in medications. Nicotine, however, is not the harmful component of tobacco. Harm comes from the 4,800 hazardous chemicals in cigarette smoke (see below). NRT is safe and when you are getting NRT you are not getting the 4,800 hazardous chemicals that come with smoking cigarettes. Likewise, people don't die from using nicotine meds, they do die of smoking cigarettes.

6. Address withdrawal concerns:

Nicotine withdrawal effects include:

• Depression
• Insomnia
• Irritability/frustration/anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Increased appetite/weight gain
• Decreased heart rate
• Cravings

It must be noted here that most symptoms peak 24–48 hours after quitting and subside within 2–4 weeks.

7. There are many products available for you and your doctor to choose from:

• Nicotine gum
• nicotine lozenge
• Nicotine transdermal patch
• Nicotine nasal spray
• Nicotine inhaler
• Zyban
• Chantix

8. The advantages of nicotine replacement:

• Reduces physical withdrawal from nicotine
• Eliminates the immediate, reinforcing effects of nicotine that is rapidly absorbed via tobacco smoke
• Allows patient to focus on behavioral and psychological aspects of tobacco cessation

9. Encourage Behavioral change:

• Fewer than 5% of people who quit without assistance are successful in quitting for more than a year
• Few patients adequately plan and prepare for quitting on their own
• Many patients do not understand the need to change behavior.
• Often, patients think they can just "make themselves quit."
• Patients who get help are more likely to be able to quit for good."

Triggers for tobacco use: What situations lead to temptations to use tobacco?

Routines/situations associated with tobacco use:

• When drinking coffee
• While driving in the car
• When bored or stressed
• While watching television
• While at a bar with friends
• After meals
• During breaks at work
• While on the telephone
• While with specific friends or family

Control your environment:

• Create a tobacco-free home and workplace: Don't let other smoke around you
• Actively avoid trigger situations as listed above
• Modify behaviors that you associate with tobacco
• Create substitutes for smoking: nicotine gum, etc.

10. Note facts: It is not nicotine that causes health problems, it is the 4,800 chemicals in cigarettes. Nicotine replacement therapy is not addicting because you receive smaller doses that can be controlled. You cannot control the amount of nicotine in a cigarette.

Some chemicals in cigarettes besides nicotine include:

• Arsenic
• Acetic Acid
• Acitone
• Ammonia
• Benzene
• Butane
• Cadmium
• Carbon Monoxide
• Ethanol
• Formaldehyde
• Hydrazine
• Hexamine
• Hydrogen Cyanide
• Lead
• Methane
• Methanol
• Naphthalene
• Nickel
• Phenol
• Polonium
• Steric Acid
• Styrene
• Tar
• Toluene

Consider the following facts about quitting smoking:

• Within hours after you stop your carbon monoxide level falls to normal and the oxygen in your blood increases
• One day after you stop your risk for heart attack starts to go down
• Two days after you stop your nerve endings start to repair themselves so your senses of taste and smell start to return to normal
• Two weeks after you quit your lungs are working 30% better than before you quit
• Within 1-9 months lung function continues to improve, cough, sinus congestion, fatigue and shortness of breath all decrease as your lungs regain normal function
• Within one year your risk of heart disease is cut in half.
• Within 15 years risk of stroke, lung cancer and heart disease are that of a person who never smoked, and you can consider yourself fully healed.

10. Allay the fallacies:

• "Smoking gets rid of all my stress." Truth: There will always be stress in one’s life.
• "I can’t relax without a cigarette." Truth: There are many ways to relax without a cigarette.
• Smokers confuse the relief of withdrawal with the feeling of relaxation.
• Second hand smoke is safe. Truth: Studies show even short term exposure to 2nd hand smoke can increase the risk of heart attacks and cancer. It also increases childhood risk of respiratory tract infections like RSV and bronchiolitis, which can lead to hospitalization and even death. It's also linked to increased risk for sudden infant death syndrome (SIDS). It also causes asthma attacks and is even linked to causing asthma.
• Third hand smoke is safe. Truth: The smell of smoke in your house and on your clothing has also been linked to disease.

The following are the five R's to motivate a patient to quit smoking as per the Certified Respiratory Therapy Review Guide (2010, page 273):

1. Relevance: Use facts to encourage patient to indicate why smoking is relevent (risk to my own health, risk to my family and friend's health, etc.)
2. Risks: Ask patient to identify the negative consequences of tobacco use. Highlight those that are most relevent to patient: shortness of breath, exacerbation of asthma, harm to pregrancy, impotence, risk of heart attack, cancer and stroke. Also, increased risk of health complications for others.
3. Rewards: Ask the patient to identify potential benefits of quitting. Examples: Smoking will improve your health, smell, taste, length of life, improve self esteem, good example for kids, have healthier babies and children, stop forcing others to breath in your smoke, feel better, perform better physically, reduced wrinkles, etc.
4. Roadblocks: Ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem solving, pharmacotherapy) that could address these parriers. Typical bariers might include withdrawal symptoms, fear of failure, weight gain, lack of support, depression, and enjoyment of tobacco.
5. Repeat: Repeat all the above motivational interventions as needed.

This post based on this power point presentation by the Michigan Department of Community Health. I also used some information from this power point presentation MSFH.